Customer Order Form

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Purchase Order #

Company Name *

Contact Name *

Email Address *

Phone *

Fax

Alternate Contact Name

Billing Address

Street *

City *

State/Province *

Postal Code *

Country *

Shipping Address

 Shipping Address same as Billing

Street *

City *

State/Province *

Postal Code *

Country *

Preferred Shipping Method *

Check all that apply. WCG will provide freight estimates for all methods selected.

 Ocean Air
 UPS DHL FedEx Cheapest Method Will Arrange Own Shipping**
Other (Specify)

**WCG will need the freight forwarder’s information to arrange
pick‐up.**

Special Requirements ***

(check all applicable types and list instructions)

***Extra charges and processing time apply for special labeling and packing/kitting***

 Custom Labels Packing/Kitting Other
List Instructions

Products (enter the quantity for each product you would like to order)

Aspirators:

PLUS: Ipas MVA Plus® Aspirator
SVS‐LF: Single Valve Aspirator (Unsterile)
SVS‐S10: Sterile Single Valve Aspirator 10 Pack

Ipas EasyGrip® Cannulae:

SR4: Size 4mm
SR5: Size 5mm
SR6: Size 6mm
SR7: Size 7mm
SR8: Size 8mm
SR9: Size 9mm
SR10: Size 10mm
SR11: Size 11mm
SR12: Size 12mm

3mm & Flexible Karman Cannulae:

To use with Ipas MVA Plus® Aspirator, adapters required. To use with Single Valve Aspirators, cannulaes sizes 3mm, 4mm, 5mm, or 6mm required.
EB3: 3mm Cannulae for Endometrial Biopsy
FC4: Size 4mm
FC5: Size 5mm
FC6: Size 6mm
FC7: Size 7mm
FC8: Size 8mm
FC9: Size 9mm
FC10: Size 10mm
FC11: Size 11mm
FC12: Size 12mm

Accessories:

AK‐PLUS: Accessory Kit for Ipas MVA Plus® Aspirator
AK‐SVS: Accessory Kit for Single Valve Aspirator
ADP‐SET: Adapter Set (6mm‐10mm)
ADP‐6MM: Adapter Set (6mm ‐ Set of 5)
DD5‐S: Denniston Dilators (Set of 5: 5mm/6mm, 7mm/8mm,
9mm/10mm, 11mm/12mm, 13mm/14mm)
MRL15CC: 15cc Bottle of Silicone
2CC‐10: 2cc Silicone Tubes (Set of 10)
UPM: Uterine Pelvic Model

Documentation Requirements (in addition to Commercial Invoice and Packing List, if needed.)

 ISO Certification CE Certification Certificate of Analysis Certificate of Origin ( Certified by Chamber of Commerce) Certificate of Origin (Certified by Manufacturer) Certificate to Foreign Government (Certificate of Free Sale)
Other (Specify)

*required field